The RheumNow Week In Review Were Number One%21 %288.17.18%29 Save

It's the 08/18/2018. This is a RheumNow Weekend Review. Hi, I'm Doctor. Jack Cush, Executive Editor of roomnow.com. This week in the news, a big wake up call for patients with psoriatic arthritis.

We all know that comorbidity kills, certainly makes life really miserable when it doesn't kill you. It really screws up drug responses and a whole bunch of stuff which we'll discuss. And lastly, we'll talk about the quote, lies, damn lies and statistics. What happens when you don't have the statistics? Let's start with a report about hepatitis C and rheumatoid arthritis.

I've seen these reports over the years. They've come out of Southeast Asia, usually Korea, Taiwan, and whatnot, and talk about hepatitis C being associated with increased risk of rheumatoid arthritis. It's primarily been seen there. It's not been seen in other parts of the world. I'm not sure what to make of it except this report is kind of interesting because this is a large claims data report from Taiwan that took patients who had hepatitis C and looked at what the risk of developing RA was if you received interferon based therapy and if you didn't.

Turns out that if you receive interferon based therapy for the hepatitis C, the risk of developing rheumatoid arthritis was significantly lower. In fact, it was thirty seven percent significantly lower with a hazard ratio of zero point six three and that was significant and that was again compared to those who did not receive interferon based therapies. There might well be something to this or maybe it is that patients who are otherwise predisposed need that extra push and in this case, it might be a chronic viral infection that gives the push. Interesting data. Other interesting data comes from Australian database of RA and psoriatic arthritis patients that actually looks at the risk of developing comorbidities and actually intends to compare the risk of comorbidity if you have rheumatoid arthritis or if you have psoriatic arthritis.

Turns out that across the board, psoriatic arthritis wins with a significantly higher, twofold higher risk of developing depression, hypertension, hyperlipidemia, diabetes, ischemic heart disease. You know, there's a lot of talk about the risk of comorbidities and obesity, in psoriasis and psoriatic arthritis and that it is large, It's a major factor in those outcomes. And many, experts in that field suggest that the risks are higher than that seen in rheumatoid arthritis. I'm not sure I've ever believed it, but there's a number of lines of evidence like this that sort of suggests it is true that maybe such patients are constitutively at higher risk for comorbidities and maybe it is driven to some extent by obesity. But again, I think it's something we really need to pay attention to.

Speaking of comorbidity, RA patients and cancer, we're worried about that association. A very interesting study looked at patients who have RA, who develop, cancer, lung cancer specifically, and looks at the outcomes. Basically showed those who had rheumatoid arthritis, who developed lung cancer were likely to be diagnosed with their cancer at advanced stage of disease. They tend to have poor outcomes, tend to have poor functional scores. Again, they tend not to respond very well to surgery, radiotherapy, chemotherapy, and other targeted therapies suggesting that RA is a bad comorbidity if you've got cancer.

We certainly know the reverse is true, but you know, again, this is one of those situations where RA patients probably are at higher risk for cancer regardless of the therapies they take. And we do think that such risks are related to inflammation and uncontrolled disease. So because of this talk of co morbidities, actually did a report, today or actually yesterday, Thursday, on what co morbidity does to disease risk and outcome risk. And it's an interesting report and I think you should look at it because it talks about, we know that things like, obesity impairs outcomes, but bottom line is that if you have a comorbidity, you're less likely to respond to existing therapy and includes a number of comorbidities, heart, cancer, obviously, obesity, hyperlipidemia, diabetes, and they've looked at patients with rheumatoid arthritis, psoriasis, psoriatic arthritis and spondyloarthritis and shown that overall drug survival is not as good, responses to therapy are not as good, higher disease activity in such patients. Again, this speaks to co morbidity being a big big issue in rheumatology.

The problem is we pay no attention to it. We give it a lot of lip service. We do nothing about it. We assume that the primary care doctor is taking care of us because that's their job. My job is arthritis.

Well, the fact is your patients who see you and love you think you're the best thing and their best doctor. In fact, they come to you for all their medical care. So that's the problem. They don't go to their primary care doctor. I put in a few bullets in there as to what we should be doing.

Number one, we should insist they have a primary care. Two, we should insist on vital signs. Number three, we should insist on cross communication. And lastly, rheumatologists and specialists need to take the bull by the horns, identify comorbidities, start the comorbidity management algorithm and then turn it over to primary care. Again, comorbidity is killing our patients chance of good outcomes.

If we don't deal with this, our patients are going to suffer and doesn't take that much more out of your time to identify hypertension, hyperlipidemia, hyperglycemia, and the risk of diabetes, obesity, and have a plan for managing obesity and smoking cessation, etc. These things should all be a part of our regular care. Speaking of what happens in regular care, a very large study of RA patients looked at what happens when you have steroid therapy and what the complications of that are. So The UK clinical practice database, a large research database was analyzed looking at RA patients and non RA patients and show that RA patients have significantly higher rates of serious adverse events. When they looked at RA patients who were on and were not on steroids, they showed that steroid use was associated with horrible outcomes.

This is chronic steroid use, and we're talking about a thirty three percent increased risk of diabetes, a forty one percent increased risk of osteoporosis, a twenty eight percent increased risk of myocardial infarction, serious infection and strokes, and a thirty three percent overall increase in the mortality rate suggesting that chronic steroids are not a good thing. In this data set, they showed that many of these were dose related so that higher doses give an even higher risk. So again, if your patients are on chronic steroids, they're not going to do well because you're relying on chronic steroids and the outcomes of such patients is not good. This week I came across an interesting question about what do you do about MCV levels that are rising in patients who are on chronic methotrexate therapy? Well, and my own practice has taught me that don't do anything.

It's not really worth chasing down an MCV of 101 or when it changes from one zero one to one zero four or one zero five when they're on methotrexate. Turns out there's no association between rising MCV levels and hematologic toxicity associated with methotrexate and its chronic use. This led me to believe maybe an MCV levels would actually be useful in identifying the efficacy of the drug. It's a marker that they're actually taking it. Maybe it correlates with polyglutamation.

I don't look at polyglutamate levels in managing my patients. It could be a way of telling whether the patient is taking the drug or not. I sent an email to Lisa Stamp, an expert on methotrexate and polyglutamation and she said that there probably is some correlation between PG1 and the combined PG1 through five but not other individual polyglutamate levels suggesting that maybe your MCV levels could be a surrogate marker. Someone needs to do that research. Not me, I got other things to do.

So an interesting study comes from seminars in arthritis and rheumatism about what happens to the x-ray outcomes of psoriatic arthritis patients. I thought this was great because at ULA I saw this fabulous lecture by Gaylord Chet talking about the influence of microtrauma and repetitive exercise and work conditions in causing enthesitis and psoriatic disease. Well, this data from a longitudinal cohort shows that in PSA patients they found that there was greater degrees of x-ray damage in those patients who were in occupations that had prolonged repetitive hand movements and higher levels of finger dexterity suggesting that physical trauma adds to the risk of not only developing the disease but maybe also the worsening of disease. A really sobering data comes from Norway. Arti Cavanagh is on his paper, Glenn, I forgot Glenn's last name, is a lead author on this.

A study of three thirty one PSA patients followed for ten years showed that over this ten year period there was no increase in remission rates when measuring remission by either DAPSA or by Boolean remission. Remission. It was significant however for CDI and DAS ESR emissions, but not in the last five years, only in the first five years, suggesting we're not doing that good even though time has gone on we've become more aggressive on therapy. Also not significant were changes in patient reported outcomes, or there was not an increase, also there was not an increase in DMARDIN biologic use over this ten year period. In this subset from Norway where they are as aggressive as we are in North America, the data is lousy suggesting that we need to be more aggressive, we need better outcomes in patients with psoriatic arthritis.

There's an interesting report from France and Xavier Mare's group about early exposure to passive smoke during childhood may lead to a later risk of developing rheumatoid arthritis. This is a study of a 100,000 women, many of them during childhood, who were looked at three decades later and showed that if there was passive exposure to smoke and you were never a smoker along your rising age getting into adulthood, that the rate of developing RRA was increased one point four three, albeit it just missed significance. The confidence intervals here were zero point nine seven one point two one. However, if you were exposed to passive smoke as a child and then again thirty years later you would assume that become a smoker, now it's highly significant. It was one point six seven, a sixty seven percent increase in the risk of developing RA.

Again, know smoking is a risk factor especially for those who may be at risk. This is good data and it's backed up by data from the Nurses Health Study, another large data set. Another interesting study this week comes from Annals Internal Medicine, where a group from Sweden, Rachael and colleagues looked at the risk of developing a cancer if you had a cancer and then receive a TNF inhibitor. We do know overwhelmingly that TNF inhibitors themselves don't cause cancer. They actually see the same pattern you get in RA that's active.

So again, they do not cause cancer. If you think they do, you're way behind the data, okay? But it's a little bit unknown whether or not if you have a cancer or have had a cancer and then you receive a TNF inhibitor, will you have a higher rate of recurrence? Some of the data has looked at this and it's been based on limited data sets. When they've looked at this in Sweden they've showed that you do not have a higher rate of dying from that cancer if you had, were on a TNF inhibitor.

So here what they did was in their large data set they found, I think it was four forty seven patients with rheumatoid arthritis exposed with TNF inhibitor after a cancer, compared that to two thousand one hundred sixty four patients who were biologic naive but had a prior cancer. And the rate of cancer recurrence was not significantly higher. The hazard ratio is is one point zero six, it did cross one, confidence intervals of 0.73 to 1.54, yet the author is still kind of waffle a little bit saying we need a little bit more data and whatnot. Again, I think we need to be strong as rheumatologists and manage what we're good at, is the arthritis and use the best available therapies. Let someone else manage cancer, you manage the arthritis.

So who's number one? The data is pretty clear. Look it up on the website. I didn't bring in the list but at the top of the list was Hopkins and Cleveland Clinic and then Hospital for Special Surgery. All the usual players are in there.

Congratulations to those hospitals in the new US News and World Report rankings. I gave you the top 25. It turns out that really the top 20 are great programs. They not only provide great rheumatologic care, but they also are, great training programs, for those of you who are considering going into rheumatology. And lastly, I put a tweet out this week that said the following, guess what drugs cause a metallic taste?

Antibiotics including tetracycline and amoxicillin, lithium, certain cardiac medications and allopurinol. I was shocked by that, so I tweeted it. There's no reference by the way. I should have looked it up. I should have looked for the statistics.

There are none. When I researched this further, it turns out that if you look up dysgeusia, the formal word for a metallic taste, it's allopurinol in almost every list. But yet the data showing that allopurinol causes metallic taste is zero. It's not in the package insert. There are no studies showing this.

My own experience says it doesn't happen, but yet it shows you what happened when people get lazy and continue to report what others report. This is what happens when technology and the internet distorts the truth. We've seen this obviously with vaccines and whatnot. So again, I think this is a special kind of stupid. It's akin to what happens when people keep copying the same medical note without actually adding any thought to what's going on in the patient.

We got to avoid this. Even though we have technology, we should be better than the technology. That's it for RheumNow. Make sure you tell your friends about this podcast and this video cast. We'd like you to sign up.

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